Anxious avoidance informs behavioural interventions for individuals with cardiovascular disease: a commentary

This invited commentary refers to ‘Association of anxiety and recurrent cardiovascular events: investigating different aspects of anxiety’, by P. Leissner et al. https://doi.org/10.1093/eurjcn/zvae036. Anxiety is prevalent among individuals with cardiovascular disease and detracts from quality of life and overall wellbeing. Clinical presentations of anxiety may involve cognitive, emotional, somatic, and behavioural components and may be generalized or specific to the context of cardiovascular disease. Research on the association between anxiety and cardiovascular disease has indicated that anxiety may have both adverse and protective effects on cardiovascular outcomes. Varied clinical presentations and mixed research findings warrant nuanced investigations to delineate the precise relationship between anxiety and cardiovascular outcomes. In their recent paper, Leissner et al.1 examined the association between different aspects of anxiety and recurrent major adverse cardiovascular events (MACE) among post-myocardial infarction (MI) patients, finding that higher cardiac anxiety, specifically anxious avoidance, was associated with increased risk of MACE. Based on findings such as those reported by Leissner et al., it may be reasonable to hypothesize that interventions to reduce anxiety among individuals with cardiovascular disease may have promise for preventing or mitigating MACE. However, a recent systematic review concluded that psychological interventions for individuals with cardiovascular disease probably do not reduce MACE.2 This disappointing conclusion must motivate researchers to conduct investigations that elucidate the nature of the association between specific anxiety components and cardiovascular outcomes with the ultimate goal of informing optimized interventions that have the potential to positively impact cardiovascular or other physical health outcomes. In demonstrating that anxious avoidance, in particular, is related to heightened risk of MACE, Leissner et al. help advance towards this goal by identifying a specific potential target of intervention, but more work is needed. One pathway forward may be to consider the association between mental health, such as anxiety, and health behaviours, such as physical activity, and develop interventions that directly attend to both of these domains. When mental health and health behaviours are addressed separately, the impact on patient health and wellbeing may be comparatively limited. Indeed, in discussing their results, Leissner et al. note that their findings may be viewed as supporting the proposal that behaviour mediates the relationship between anxiety and cardiovascular outcomes. They suggest that providing additional support to individuals with anxious avoidance may help them help them engage in physical activity, ultimately improving their wellbeing. While targeting anxiety is likely to enhance quality of life, it may be an insufficient approach if the long-term goal is to also improve cardiovascular and physical health outcomes.2 Considering the pathway by which anxiety and cardiovascular outcomes are related may enhance the comprehensiveness and potential effectiveness of interventions. A possible mechanism is that anxious avoidance hinders participation in physical activity, which in turn results in diminished cardiorespiratory fitness, a predictor of MACE and mortality. For example, a study of cardiac rehabilitation participants found that anxious avoidance at admission predicted reduced physical activity, lower exercise capacity, and poorer quality of life.3 In this paradigm, interventions should aim to reduce cardiac anxiety and promote physical activity, with a focus on how cardiac anxiety, specifically anxious avoidance, and physical activity relate. Two constructs, kinesiophobia and anxiety sensitivity, have relevance to both cardiac anxiety and physical activity and may help guide future interventions. Kinesiophobia, the fear of movement, is prevalent among patients with cardiovascular disease and is correlated with cardiac anxiety.4 Encouragingly, progressive muscle relaxation may reduce kinesiophobia.5 Anxiety sensitivity refers to the belief that anxiety symptoms have harmful consequences and is elevated among individuals with cardiovascular disease.6 Physical activity produces physiological arousal that may mimic anxiety symptoms for some individuals, possibly leading to avoidance of physical activity. Positively, mindfulness strategies have been shown to reduce anxiety sensitivity.7 Both progressive muscle relaxation and mindfulness strategies could be readily incorporated into interventions for anxiety or offered as supplements in physical activity interventions. In addition to promoting positive cardiovascular outcomes, a further benefit of interventions that address both anxiety and physical activity is that physical activity may reduce anxiety.8 While including both anxiety and physical activity content may help optimize interventions, it is also critical that future behavioural interventions to enhance cardiovascular health are appropriate for the target population. Leissner et al. used data from their U-CARE Heart Trial,9 a randomized controlled trial of an internet-delivered, therapist-led cognitive behavioural intervention (iCBT) for post-MI patients. Because engagement with iCBT was low and it had no observed effect on anxiety, participants who had been randomized to receive iCBT were included in the primary analyses for their recent paper. Low treatment adherence for interventions such as iCBT should raise concerns for professionals working to improve cardiovascular health through behavioural change. Although iCBT contained modules labelled Fear and Avoidance Post-Myocardial Infarction and Applied Relaxation Training, which appear highly relevant and potentially beneficial for those with elevated anxious avoidance, the proportion of trial participants that initiated (6% and 24%, respectively) and completed (3% and 4%, respectively) these modules was low. Without intervention content, delivery, and presentation that is accessible, appealing, engaging, and meets the needs of the target population, intervention effectiveness and implementation are likely unachievable. It is incumbent upon those who design and trial behavioural interventions to use methods and approaches that will confer the strongest chance for the intervention to reach relevant individuals and practice settings. In important work exploring participants’ experience of iCBT,10 the author group reported that participants expressed preference for less focus on depression and anxiety in the intervention and indicated that the intervention evoked unpleasant emotions. It is possible that added focus on physical activity or other relevant health behaviours may have decreased the perception of emphasis on emotional distress and may have engaged a larger number of participants in the intervention. The author group also highlighted other highly valuable strategies in response to low iCBT engagement, including the importance of engaging members of the target population early in the intervention development and design process and the value of usability of feasibility studies to refine interventions prior to larger-scale testing. Moving forward, it is hoped that Leissner et al. and other research groups will incorporate strategies to address mental health and health behaviours in interventions to promote cardiovascular health via user-centred processes that will enhance the likelihood of intervention uptake and ultimately effectiveness. There are no new data associated with this article.